POSTPARTUM HAEMORRHAGEMOHD HANAFI BIN RAMLEE

MBBS IIIB

1

PPH: DEFINITION

PPH is generally defined as blood loss greater than or equal

to 500 ml within 24 hours after birth, while severe PPH is

blood loss greater than or equal to 1000 ml within 24 Hours.-WHO-

Conception

22 weeks

Foetal viability

24 hours 6 weeks

ANTEPARTUM HAEMORRHAGE

POSTPARTUM HAEMORRHAGE

PRIMARY SECONDARY

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PRIMARY PPH: AETIOLOGY

TONE [Abnormality Of Uterine Contraction]

• Over distended uterus

• Uterine muscle exhaustion / Uterine Atony [90%]• Intra amniotic infection

• Functional/anatomic distortion of the uterus

TISSUE [Retained Product Of Conception]

• Retained products

• Abnormal placenta

• Placenta Praevia /Abruptio Placenta• Blood clots and cotyledon

TRAUMA [At Genital Tract]

• Cervix, vagina , perineum laceration• Caesarean section laceration

• Uterine rupture

• Uterine inversion

THROMBIN [Abnormality Of Coagulation]

• Coagulopathy• therapeutic

4T’S AETIOLOGY OF PRIMARY PPH

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SECONDARY PPH: AETIOLOGY

1. Retained products of conception

2. Infection

3. Breakdown of uterine wound

4. Chronic sub-involution of uterus

5. Thophoblastic disease (rare)

6. Endometrial cancer (rare)

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PPH: UTERINE ATONY

• Most dangerous• Uterus although empty, fail to contract and

control bleeding from the placental sitefollowing the delivery of the placenta.

PREDISPOSING FACTOR

• Over distention of uterus (multiple pregnancy, polyhydromnious, macrosomia)• Retained product of conception• Prolonged labour• Oxytocin augmentation of labour• Grandmultiparity• Antepartum haemorrhage• Uterine fibroid• General anesthetic drugs (halothane)• Precipitate delivery• Chorioamnionitis• Magnesium sulphate treatment of PIH• Anemia

5/15

PPH: RETAINED PLACENTA

• Defined as failure of the placenta to be expelled within 30 minutes after delivery of the fetus.

• 2% of deliveries continues bleeding

• Causes:

– Placenta separated but undelivered

– Placenta partly or wholly attached

– Placenta accreta

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PPH: GENITAL TRACT TRAUMA

• Commonly follow an assisted delivery (forceps, ventouse)

• Episiotomy can sometimes extends upwards and cause bleeding.

• Uterine rupture at

– previous caesarean section

– previous myomectomy

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PPH: UTERINE INVERTION

• Uterus pushed “inside out”, fundus at the introitus• A rare complication.• Commonly occur due to mismanagement of third stage of

labour (controlled cord traction is applied when the uterus is not contract, or excessive fundal pressure)

• Uterine atony and uterine anomalies.– First Degree- (Incomplete)-inverted fundus reached the external os. – Second Degree- (Complete)-whole body of the uterus is inverted and

protudes into the vagina– Third Degree- prolapse of inverted uterus, cervix and vagina outside the

vulva• Consequences

– Severe shock - anuria and renal failure– Sepsis– Chronic inversion– Uterus strangulate and slough off

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MANAGEMENT: POSTPARTUM HAEMORRHAGE

MOHD HANAFI BIN RAMLEEMBBS IIIB

9

At ANE: INITIAL ASSESSMENT AND START BASIC TREATMENT

Call for help

Assess Airway, Breathing, Circulation [ABC]

Provide Supplementary Oxygen

Obtain an intravenous line

Start fluid replacement with IV crystalloid

Monitor Vital SignCatheterize bladder and

monitor urine output

Assess need for blood transfusion

Lab test

•FBC, Coagulation

•Blood Group

•Cross Match

10/15

ANE to OT: TEMPORIZING AND TRANSFER INTERVENTION

Ready to refer

DrugsUterine

Massage

Bimanual Uterine

Compression

External Aortic

Compression

Intrauterine Balloon / Condom

To OT

ANE to OT: DRUGS OF CHOICE

Oxytocin ErgometrineProstaglandin

• Misoprostol

• PG F2alpha

Tranexamic acid

If not available or bleeding still continue from previous drugs

ANE to OT: TORRENTIAL BLEEDING

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OT: FINDING THE CAUSES

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OT: SURGICAL TECHNIQUES FOR PPH

Uterine compression sutures

• B-Lynch suture & modifications.

• Hemostatic suturing technique

Devascularisation procedure

• Bilateral uterine artery ligation.

• Bilateral internal iliac artery ligation.

• Utero-ovarian artery anastomosis ligation.

• Arterial embolization.

Indication of Hysterectomy (Supracervical / Total)

• Uterine atony

• Placenta accreta

• Placenta previa

• Uterine laceration

• Uterine rupture

• Uterine leiomyomata

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OT: B-LYNCH SUTURE

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SUMMARY

• Hemorrhage is one of the four leading causes of maternal mortality.

• The average blood loss from an uncomplicated vaginal delivery is 500 mL, and for cesarean delivery it averages 1,000 mL.

• Although there is no universally accepted definition for postpartum hemorrhage, it would seem reasonable to define postpartum hemorrhage as blood loss that produces signs and symptoms of hemodynamic instability.

• Postpartum hemorrhage may be due to uterine atony (the most common cause), genital tract lacerations, retained products of conception, or defection coagulation.

• Medical management pertains primarily to the treatment of uterine atony and/or associated coagulopathy.

• Blood volume replacement should begin with crystalloid followed by packed red blood cells to maintain a urine output of 25 to 30 mL or more per hour and the hematocrit at or near 30% (

• Uterine packing should be used primarily as a temporizing method to allow time for adequate volume replacement prior to laparotomy.

• Surgical techniques for the management of postpartum hemorrhage include uterine compression sutures, uterine artery ligation, internal iliac artery ligation, and hysterectomy

THANK YOU!!!15/15